- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,944.53 / $1,944.53 / $1,944.53
| Facility | | $1,944.53 | $1,944.53 | $1,944.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.70 / $1,861.02 / $1,944.53
| Professional | | $1,812.70 | $1,861.02 | $1,944.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,520.21 / $5,081.29 / $6,586.86
| Facility | | $2,520.21 | $5,081.29 | $6,586.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,446.55 / $2,714.08 / $4,652.71
| Professional | | $2,446.55 | $2,714.08 | $4,652.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $4,543.67
| Facility | | $2,326.75 | $2,326.75 | $4,543.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $18,495.00
| Professional | | $1,698.53 | $2,326.75 | $18,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.49 / $1,877.77 / $3,129.62
| Professional | | $1,440.49 | $1,877.77 | $3,129.62 |